Nursing: The Nursing Process and Safety

The Nursing Process (ADPIE)

• Assessment involves collecting subjective (patient-reported) and objective (observed/measured) data.
• Always assess before acting, unless otherwise instructed in the question.
• Diagnosis should use NANDA-approved nursing diagnoses.
• Focus on patient responses to health problems, not medical conditions, when formulating a diagnosis.
• During planning, prioritize using ABCs (Airway, Breathing, Circulation), Maslow's Hierarchy, safety, and pain.
• Set SMART goals: Specific, Measurable, Attainable, Realistic, Time-bound.
• Implementation involves carrying out interventions; reassess if needed.
• Interventions should be evidence-based and within your scope of practice.
• Evaluation determines if outcomes were met and modifies the plan as needed.

Safety & Infection Control

• Standard Precautions are used with all patients and include hand hygiene and gloves when in contact with fluids.
• Airborne precautions require an N95 respirator and a negative pressure room for conditions like TB, measles, and varicella.
• Droplet precautions necessitate wearing a mask within 3 feet of the patient for illnesses like flu, mumps, and pertussis.
• Contact precautions require gloves and a gown for conditions like MRSA and C. difficile.
• The correct order for donning PPE is: Gown → Mask → Goggles → Gloves.
• The correct order for removing PPE is: Gloves → Goggles → Gown → Mask.
• Fall prevention measures include using bed alarms, non-skid socks, and keeping the call light within reach.

Vital Signs

• Normal temperature range: 97.8-99.1°F (36.5-37.3°C).
• Normal pulse range: 60-100 bpm.
• Normal respiration range: 12-20 breaths/min.
• Normal blood pressure: Less than 120/80 mmHg.
• Normal oxygen saturation: 95-100%.
• Use apical pulse for 1 minute before administering cardiac medications.
• Orthostatic vitals involve measuring blood pressure and heart rate while lying, sitting, and standing; a drop in BP and a rise in HR indicate a positive result.

Mobility & Immobility

• Risks of immobility include pressure ulcers, DVT, pneumonia, constipation, and contractures.
• Interventions for immobility involve turning the patient every 2 hours (q2h), using compression devices, and encouraging fluids and mobility.
• When using a cane, it should be held on the opposite side of the affected leg.
• When using a walker, the patient should move the walker, then the weak leg, and then the strong leg.
• When using crutches, follow the "up with the good, down with the bad" rule on stairs.

Nutrition

• The diet progression is: Clear liquid → Full liquid → Soft → Regular.
• A low sodium diet involves avoiding canned and processed foods.
• A renal diet is low in protein, potassium, and phosphorus.
• A diabetic diet should consist of balanced carbohydrates while avoiding sugar.
• Confirm placement of enteral feeding tubes (initial: X-ray, ongoing: pH < 5).
• Keep the head of the bed elevated 30-45° and check residuals during enteral feeding.

Elimination

• <30 mL/hr of urine output may indicate a possible renal issue.
• For Foley care, keep the bag below the bladder and clean the perineum from front to back.
• When administering an enema, position the patient in Sims' (left side) position.
• Monitor for constipation, diarrhea, and impaction.
• An ostomy stoma should be pink and moist; report any dusky or dry appearance.

Medication Administration

• The 6 Rights of medication administration are: Right patient, right drug, right dose, right time, right route, and right documentation.
• For IM injections, use a 90° angle and Z-track technique for irritating medications.
• For SubQ injections, use a 45-90° angle depending on the amount of fat.
• High-alert medications include insulin, anticoagulants, and opioids.
• Documentation of medication administration should occur immediately after administration.

Documentation & Legal/Ethical Principles

• Documentation tips: Be objective, factual, and timely.
• Avoid vague terms like "appears" in documentation.
• Informed consent must be signed before sedation.
• Advance directives include a living will and durable power of attorney.
• HIPAA protects patient privacy.
• Ethical principles include autonomy, beneficence, nonmaleficence, and justice.

Communication

• Therapeutic communication techniques include active listening, open-ended questions, reflecting, and silence.
• Avoid giving advice or asking "why" questions.
• SBAR communication includes Situation, Background, Assessment, and Recommendation.

End-of-Life Care

• The stages of grief (DABDA) are Denial, Anger, Bargaining, Depression, and Acceptance.
• Palliative care focuses on symptom management at any stage of illness.
• Hospice care provides end-of-life care with no curative treatment.

Preoperative Care

• Preoperative assessment includes checking for allergies, medications (anticoagulants, insulin), and medical history (DM, cardiac).
• Preoperative teaching includes NPO status for 6-8 hours before surgery, deep breathing, incentive spirometry, mobility after surgery, and pain management options.
• Verify that consent is signed; the nurse's role is to witness, not explain the procedure.

Postoperative Care

• Immediate postoperative focus includes assessing ABCs, monitoring vital signs every 15 minutes, ensuring airway patency, and checking for bleeding.
• To prevent atelectasis, use incentive spirometry and ambulation.
• To prevent DVT/PE, encourage leg exercises and use SCDs.
• Prevent infection with aseptic wound care.
• Address paralytic ileus with ambulation and assessment of bowel sounds.
• For urinary retention, monitor output and bladder scan if needed.
• Dehiscence is the separation of a wound; evisceration is when organs are protruding.
• In the event of evisceration, cover the organs with moist saline gauze and call the surgeon.
• Discharge teaching should include incision care, signs of infection, activity limits, diet, and medication instructions.

Memory Aids

• ADPIE = Nursing Process.
• PPE On: Gown, Mask, Goggles, Gloves.
• PPE Off: Gloves, Goggles, Gown, Mask.
• "Up with good, down with bad" for crutches.
• DABDA = Grief stages.
• SBAR = Communication model.
• "A Very Sick Patient Died Eventually" = Post-op Complications: Atelectasis, VTE, SSI, Paralytic ileus, Dehiscence, Evisceration.